Vestibulo-Ocular Reflex Cancellation Test Form
Assessment and documentation of vestibulo-ocular reflex (VOR) cancellation test results. Please complete all fields accurately.
Patient Initials
*
Date of Test
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Examiner Name
*
Test Position
*
Sitting
Standing
Other
Test Method
*
Manual Head Rotation
Motorized Chair
Other
Target Type
*
Visual Target
Imaginary Target
Other
Test Direction
*
Horizontal
Vertical
Smooth Pursuit Performance
*
1
2
3
4
5
VOR Suppression Quality
*
Poor
1
2
3
4
Excellent
5
1 is Poor, 5 is Excellent
Observations Table
Rows
Present
Absent
Saccades
1
2
Nystagmus
3
4
Head Movement Artifact
5
6
Submit Assessment
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